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J Thorac Cardiovasc Surg 1997;114:1123-1125
© 1997 Mosby, Inc.

LETTERS TO THE EDITOR

A temporary bidirectional superior vena cava–pulmonary artery shunt

William W. L. Glenn , MD

Department of Surgery
Yale University School of Medicine
333 Cedar St.
Box 3333
New Haven, CT 06510
12/8/85518

To the Editor:

My experience with the bidirectional shunt was in experiments in the mid-1950s, when Dr. José Patiño and I were exploring several techniques for establishing a bypass of the right side of the heart. Three basic shunts were made: superior vena cava–right pulmonary artery (SVC-RPA), inferior vena cava–right pulmonary artery, and total venous bypass. Our attempt to achieve a total venous bypass made use temporarily of a bidirectional superior vena cava–pulmonary artery shunt. Published drawings of the total bypass procedure did not reveal the details of the bidirectional shunt. However, Dr. Patiño made an excellent drawing of the procedure in the protocol book, which clarifies the technique used (Fig. 1). The bidirectional shunt as used by us was not an integral part of the operation but a temporary means of expediting completion of a total bypass as used in our experiments. If there is any merit in publishing the drawing, it is that it illustrates an early technique for making a bidirectional shunt.



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  		Fig. 1. Complete bypass of right side of heart. SVC, Superior vena cava; PA, pulmonary artery; IVC, inferior vena cava; RA, right atrial; RPA, right pulmonary artery.

 
After more than 3 years in the experimental laboratory, we selected the SVC-RPA shunt to apply clinically, principally because it was the safest and technically the simplest of the venous bypass operations. We had such good luck with the SVC-RPA shunt in patients with normal pulmonary arteries that there was no incentive early on to abandon it. In 1990 Kopf and associatesGo 1 reported a total of 49 (more recently 54) patients having an SVC-RPA shunt in our clinic with the diagnosis of single ventricle or tricuspid atresia with no operative mortality. I doubt we would have done as well in the early days using the more complicated bidirectional shunt. In the 1950s and 1960s, with limited experience with the SVC-RPA shunt and no experience with the Fontan procedure, no one could anticipate the potential benefits of a bidirectional shunt in the treatment of complex malformations of the heart. Not until our 1973 report,Go 2 when we described it in a number of patients with SVC-RPA shunts, did we recognize the development of widened normally occurring precapillary arteriovenous connections in the right lower lobe as a possible major cause of decreased efficiency of the SVC-RPA shunt. I recall being concerned at the time that atrioventricular connections might also develop in the left lower lobe if a bidirectional shunt was used.

The evolution of the total venous bypass of the right side of the heart and the important role of the bidirectional shunt in its progress makes a fascinating story. I have long appreciated the many hands that molded the right heart bypass operation, beginning with Rodbard and WagnerGo 3 in 1949, the first to voice the basic concept that the venous vis à tergo is sufficient to propel the venous blood through the pulmonary vascular circuit. Several weeks ago I heard a prominent pediatric cardiologist say he hoped some day it would be possible for candidates for a right heart bypass to reach the age of 70 years. I hope so, too. Our first patient to have an SVC-RPA shuntGo 4 was referred by Dr. Ruth Whittemore. He was a 7-year-old boy with single ventricle, transposition of the great arteries, and pulmonary stenosis who subsequently had additional procedures to complete the right heart bypass, by Dr. Hillel Laks, and to control the arteriovenous connections in the right lung, by Dr. William Hillenbrand, will mark the 40-year anniversary of the initial procedure in February 1998, if all continues to go well. He has had a good life. He is married, has a daughter, works full time, and in his spare time he tends a good-sized garden and plays 18 holes of golf whenever he likes.

References

  1. Kopf GS, Laks H, Stansel HC, Hellenbrand WE, Kleinman CS, Talner NS. Thirty-year follow-up of superior vena cava–pulmonary artery (Glenn) shunts. J Thorac Cardiovasc Surg 1990;100:662-71. [Abstract]
  2. Mathur M, Glenn WWL. Long-term evaluation of cava–pulmonary artery anastomosis. Surgery 1973;74:899-916. [Medline]
  3. Rodbard S, Wagner D. By-passing the right ventricle. Proc Soc Exp Biol Med 1949;71:69-70. [Medline]
  4. Glenn WWL. Circulatory bypass of the right side of the heart. IV. Shunt between superior vena cava and distal right pulmonary artery—report of clinical application. N Engl J Med 1958;259:117-220.



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